Skip to main content

It’s all in the Framing: How to Influence Surrogates' Code Status Decisions




by: Eric Widera (@ewidera)

We intuitively know that the words we choose when talking about whether or not to attempt cardiopulmonary resuscitation (CPR) may influence the decision of a surrogate. Now we have some evidence to back this up thanks to a fascinating study published in Critical Care Medicine by Drs Amber Barnato and Bob Arnold at the University of Pittsburgh.

The study randomized 256 adult children or spouses to take part of a Web-based interactive simulated family meeting.  These surrogates were asked to imagine their loved one in a hypothetical situation in which they were admitted to the intensive care unit (ICU) on life support due to a pneumonia, severe sepsis, and acute lung injury. During the simulated family meeting, the actor playing the ICU doctor tells the surrogates that their loved one has a 10% likelihood of survival to discharge in the event of cardiac arrest requiring CPR. The actor then asks the surrogate to decide the patient’s code status.  The trick though with this study is that the way this was communicated was slightly different for subjects randomized to various experimental conditions.

Condition 1: The Effect of Physician Communication Behaviors

Three framing manipulations took place at the end of the family meeting when the ICU doctor asked about the patients code status.  The results showed that:
  1. Framing treatment decisions as the patient’s, not the surrogate’s decision did NOT impact CPR choice.  (56% vs 56%)
  2. Framing the alternative of CPR as “Allow Natural Death” instead of “Do Not Resuscitate” significantly decreased the surrogates choice of CPR for their loved ones: 49% vs 61%
  3. Framing the decision as the social norm (the ICU doctor said that in her "own experience" most other family members were more likely to choose DNR) also significantly decreased CPR choice.  
    • If CPR was framed as the norm, 64% of the surrogates chose it.  
    • If no CPR was the norm, 48% chose to CPR.

Condition 2: The Effect of Attending To Emotion

Some of the surrogates were also randomized to the “emotion-attending condition” where the ICU doctor used the NURSE mnemonic (naming, understanding, respecting, supporting, and exploring emotion) and one “I wish” statement.

  • Like in Alex Smith's GeriPal video, attending to emotion using mnemonics like NURSE did NOT significantly impact decision making.  53% chose CPR in the empathic statement group vs 59% in those without empathic statements.

Condition 3: The Effect of Emotion Arousal

In this last experiment, surrogates randomized to the “emotion arousal” group saw a photo of the spouse/parent for whom they would be making the hypothetical code status decision. They were also asked to do two imagery exercises “designed to create a state of emotional attachment.”

  • Interestingly, as opposed to what you may have thought, priming the emotional attachment pump did NOT impact CPR decisions: 56% chose CPR in the emotionally aroused vs 56% in the unaroused group

Conclusions

What's the take home?   No, it's not that you needn't pay attention to emotions.  Alex's Take-Out-the-Trash video is a good example of what happens when you try to use empathic statements without actually being empathic (the authors admit that the actors just read the scripted statements and did not otherwise respond differently to the emotional content of the surrogates).

The take home is that we have a lot of responsibility when facilitating CPR discussions.  Framing CPR decisions using social norms or framing CPR's alternatives in a different light (Allow Natural Death instead of Do Not Resusciatate) can significantly influence surrogate decision-making.   Whether or not that is a good thing I'll leave to a follow-up post...


NOTE: This is the first in a series of posts this week for "Code Discussion Week." Come back everyday this week for a new post focused on CPR AND DNR Discussions.


Here is a running list of posts:

Comments

Diane Murdock said…
This article is such an important read. Framing CPR choices in the context of allowing natural death instead of "DNR" can definitely help with the difficult discussions surrounding code status. But what often persists is family believing doing something and doing everything possible is right for their loved one and for their own peace of mind. There are too many who feel devastated because of decisions not to pursue it all rather than let go. Looking forward to a follow-up post.
kathy kastner said…
Great topic - with so many layers.

Myself, I've made it clear to all who matter that I do NOT want to be revived. Clear as my directive is, I can't i
magine those who may be there when/if my heart stops or I stop breathing. Assuming the follow my wished, what trauma might they suffer watching and letting me die?

hile I fully support letting nature take its course, I humbly suggest it shouldn't be a given that the term 'Allow Natural Death' will be understood as intended: I know I'm not alone when my initial assumption was: that "natural death" meant 'no comfort measures': they're not not part of a Natural Death.'
Thanks again for opening up the convo;)
Kathy
bestendings.com
Pagan Chaplain said…
Excellent point, Kathy. Thanks for making sure this aspect is considered by those in direct care. In my experience, the term Allow Natural Death is generally followed by a short description of "Comfort Care." Your comment makes clear how important it is to do that.
Amber Barnato said…
Eric did a great job summarizing our findings. I've been publishing papers for more than a decade and this is the first one to get so much popular media coverage. The research was great fun to do and it is gratifying that it's having a broad reach. Thanks so much!

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …